Who is responsible for paying if Medicaid says "No?"

ArtMom - it’s important to understand how Medicaid gets funded & what Medicaid is. It’s a huge program from kids health programs - like CHIP - to maternal health stuff - like providing breast pumps - to underwriting a portion of the costs of community health clinics or PACE centers. These are funded by the feds to each state based on the demographics of your state. (This is 1 reason why the upcoming census is important). Then your state has to do a shared cost of each specific program that they want to include within Medicaid if funding of the program is not mandatory.

Remember when ACA / Obamacare came out and some states did not want to take Medicaid expansion under ACA? Those states could do that as participation was not mandatory for ACA.

Under existing federal law, Medicaid is mandated (required) to have dedicated funding in all states for skilled nursing care for those that show to be “at need” for SNC. SNC = NH as NH has skilled nursing level of care. States can choose if they want to fund AL (most do not) or MC (some do, some don’t) from their overall Medicaid $, and this is done via waivers that run on 3-7 yr funding cycles.

The “at need” is important as it has both medical and financial eligibility requirements. And therein lies the rub..... your state can determine what the “at need” is within overall federal guidelines. What seems to happening now is states are reviewing health charts to make sure that the person on LTC Medicaid is not just needing custodial care but needs skilled nursing care.

AND in addition to this your state determines uniquely what the daily room & board medicaid reimbursement rate paid to a facility will be. Average seems to be abt $185 a day. NH cannot operate if their beds are 100% Medicaid. They need a mix of Medicare rehab beds, private pay beds and LTC Medicaid beds to be able to operate with narrow profitability. Just what % of each kinda interdependent on what amount your state pays for daily R&B.

You know that your mom is going to run out of $.
I’d bet you can likely get her under 2k in assets point in time down to a specific month and year in the future. I would suggest you go to speak with the billing office 6 mos before that as to how to best deal with the transitioning from private pay to your mom filing for a LTC Medicaid application and going on “Medicaid Pending” status. If your mom’s been there like forever on private pay and they like her (& you) and her care is easily done, believe me, their gonna wanna keep her and have her get into 1 of their Medicaid beds. Billing & admissions may actually have ideas for you to do to get mom’s assets down like in under 30 days as they have 3 Medicaid beds open right now.

Like say mom has 34k still in savings manana (April 1st), mom could buy in full a preneed funeral & burial policy at whatever is state max allowed. Let’s say it’s 12k. 34k - 12 = 22k - 8k private pay April = 14k. You order new hearing aids & 2 sets of eyeglasses @ 2k= 12k balance. Mom goes to the dentist & gets 10,350 worth of work done (like 2 implants). Mom now impoverished with $1,650 in assets for end of April. She applies Medicaid Pending for May 1st. The NH does an internal hold on 1 of those 3 open Medicaid beds for her so she transitions to Medicaid Pending status May 1st. Happiness all around.

As an aside dental is almost always never ever covered by Medicaid or Medicare (except for dentures). If you need a big $$$ spend down & your elder needs dental stuff done & has a dentist that works with elderly, it’s a great way to do a spend down.

Really if there’s an open Medicaid bed, and you can do something totally legit to snag it for your mom, you do it. Sometimes families buy a expensive wheelchair to get beyond the spend down needed.

Medicaid cuts will be felt by those hustling the system. True need will still be met.

II personally believe it is long over due to stop the bleed.

Your mom should be fine, as it is a real need and not some lazy young person wanting to live without working.

Have there been actual Medicaid cuts in your state? Or are they proposed Medicaid cuts?

Why do you think she would be penalized? Did she give a large amount of money to someone? Did she sell a home for lower than Market Value, a car? That would be some of the reasons for a penalty. If 5 yrs of bank statements show no large withdrawals other than for her care or for her personally, I see no problem.

Whomever received the money that makes her suffer a penalty period would need to return the money or step up to care for her during that time.

If that isn't an issue, why are you concerned that she will receive a penalty?

Being POA doesn’t make you pay for care. My mother went into a nursing home as private pay, along with using a LTC insurance policy. When it ran out she transitioned right onto Medicaid. The business manager of the nursing home knew when this was coming and helped us prepare for it